Medical Education Commons^™

Likelihood Ratios For Reactions To Egg Based On Specific Ige And Oral Challenges, Melissa Anderson

Research Days

Background: Specific IgE (sIgE) to foods has been used to predict the risk of a systemic reaction (SR) when the food is ingested. An arbitrary cutoff of 0.35 is often used to separate a positive likelihood ratio (LR+) from a negative one (LR-), yet there is little evidence supporting the use of this value.

Objectives/Goal: The objective of this project was to establish a more accurate method for estimating the probability of food allergy to egg.

Methods/Design: Egg-sIgEs were measured and open oral egg challenges were performed on 155 children with a clinical history of egg allergy. Logistic regression (LR) …

Improving Advanced Therapeutic Endoscopy Performance At An Academic Children's Hospital, Julia Snodgrass, Thomas M. Attard, Donna Ditsch, John Colgan, Amanda Weston, Jessica Koch, Nadia Ibrahimi, Pang Krasaelap, Voytek Slowick, Laura Shroyer

Research Days

Problem Statement/Question: Advanced therapeutic endoscopy is infrequently needed but critical in the management of children with complex gastroenterology disorders. Hands-on experience in specific advanced techniques, set up of endoscopy equipment and familiarity with new ancillary equipment for use during endoscopy have been intra-departmentally identified as potential areas for improvement.

Background/Project Intent: Our aim is to improve provider scoring on an endoscopy practice test based on technical aspects of therapeutic techniques, indications and set up of standard and new endoscopic equipment by 20% over pre-practice session testing.

Methods: The Model for Improvement framework was utilized. A multidisciplinary team was created including …

Who Is My Child’S Main Doctor? Assessing Caregiver Perceptions Of Teaching Teams At A Pediatric Tertiary Care Center., Jonathan Ermer

Research Days

Background: The size and structure of large academic teaching teams can create a barrier to communication and relationship-building with caregivers. Studies have shown that from a patient perspective, being able to name their doctor and identify their role is important. Benefits include increased patient satisfaction, improved relationships in line with the family-centered care movement, and improved patient safety. Although important, studies in both adults and pediatrics have shown that patients and caregivers do not know who their doctors are. Acknowledging the hierarchy present on family-centered rounds is not only burdensome and confusing to patients and caregivers, but it can also …

A Case Of An Elevated Tryptase, Sonya Parashar

Research Days

Introduction: Hereditary Alpha Tryptasemia (HαT) is an autosomal dominant disorder characterized by an elevated baseline tryptase that occurs up to 3% of the population and clinically resembles mast cell activation syndrome.

Case description: A full-term, 13-month-old female patient presented to Allergy and Immunology clinic for persistently elevated tryptase. Her initial symptom was non-bloody loose stools, but she later developed recurrent flushing, joint pain, constipation, and frequent nighttime awakenings. Her past medical history included gastroesophageal reflux disease. Family history was significant for an older sibling with history of flushing. At all visits, physical examination was normal. Tryptase ranged between 11.7 - …

Evaluating Caretaker Satisfaction With Same-Day Discharge After Gastrostomy Tube Placement, James A. Fraser Md, Shai Stewart Md, Kayla B. Briggs Md, Shawn D. St. Peter Md, Tolulope A. Oyetunji Md Mph

Research Days

Background: Same-day discharge (SDD) after outpatient laparoscopic gastrostomy tube (G-tube) placement has been our standard institutional practice since 2017, following written and video-based preoperative education regarding G-tube use, maintenance, and exchange at the time of consultation.

Objectives/Goal: We aim to evaluate caretaker satisfaction with our same day discharge protocol following laparoscopic gastrostomy tube placement.

Methods/Design: Following IRB approval, all patients planned for SDD after G-tube placement from FebruarySeptember 2021 at a tertiary care academic center were identified. Retrospective chart review was performed to identify demographic information, successful same-day discharge or reason for postoperative admission, time to first postoperative feed, length …

Recurrent Primary Spontaneous Pneumothorax Masquerading As A Congenital Pulmonary Airway Malformation In A Young Female, Chandra Swanson

Research Days

Background: Spontaneous pneumothoraxes in children are uncommon, may be idiopathic or associated with underlying pulmonary disease, and can present management challenges.

Objectives/Goal: We present a 12-year-old female with recurrent right sided spontaneous pneumothorax in the setting of an asymptomatic SARS-Co-V2 (COVID) infection and imaging concerning for congenital lobar overinflation (CLO) versus congenital pulmonary airway malformation (CPAM), prompting surgical intervention.

Methods/Design: A literature review and chart review were completed for this case report.

Results: A 12-year-old pre-menstrual female with remote history of eczema, asthma, and environmental allergies presented from an outside facility with four-days of progressive chest pain and dyspnea on …

Factors Leading To Reduced Unscheduled Pediatric Asthma Visits During Covid-19, Sean Stout

Research Days

Background: Emergency Department (ED) and inpatient (IP) asthma visits were reduced during 2020 at a tertiary pediatric hospital. This was likely due to measures used to avoid exposure to the SARS-CoV2 virus which led to fewer viral upper respiratory infections (URIs). Other known asthma triggers include allergens, air pollution, and weather changes.

Objectives/Goal: To determine whether other factors could explain this reduction, we looked for changes in other asthma triggers such as pollen, air pollution, and weather.

Methods/Design: Monthly ED and IP asthma visits from 2010 to 2019 were compared to 2020 by time series analysis (TSA), controlling for total …

Feeding And Swallowing Disorders In 100 Children With 22q11.2 Syndrome, Jana Ghulmiyyah

Research Days

Watch recording of live event

Background: 22q11.2 deletion syndrome (22q11DS) is the most common microdeletion syndrome. The syndrome includes a wide range of variable features including congenital heart disease, palatal abnormalities, immune deficiency and learning difficulties. Otolaryngologic manifestations include hearing loss, characteristic facial features and laryngotracheal abnormalities. A few studies have reported dysphagia as a common feature of this syndrome however little is known about the specific feeding and swallowing difficulties that occur in children with 22q11DS.

Objectives/Goal: The aim of the study is to identify the frequency of feeding and swallowing disorders in a large cohort of pediatric patients …

Evaluation Of A Modified Pre-Medication Algorithm For Non-Emergent Intubation In A Neonatal Intensive Care Unit, Lilah Melzer

Research Days

Watch recording of live event

Background: The use of pre-medication for elective non-emergent intubation in neonates and infants has been suggested to minimize physiologic instability, decrease oral/pharyngeal trauma and decrease time and attempts to successful intubation. A pre-medication algorithm including the use of Fentanyl + Atropine was modified to include a higher dose of fentanyl with addition of muscle relaxant and benzodiazepine in a level IV neonatal intensive care unit.

Objective: The objective of this study was to compare first attempt success of intubation pre- vs post-modification of the pre-medication algorithm.

Methods: This is a single site retrospective chart review. …

Inpatient Outcomes For Children Receiving Empiric Methicillin-Resistant Staphylococcus Aureus Coverage For Complicated Pneumonia, Sophia Hackman

Research Days

Watch recording of live event

Background: Pediatric community acquired pneumonia is responsible for an estimated 124,000 hospitalizations annually in the United States, with up to 40% of hospitalized children subsequently developing a complicated pneumonia (i.e., effusion/empyema). Children with complicated pneumonia commonly require increased numbers of procedures, have exposure to broad-spectrum antibiotics, and have prolonged hospitalizations. While the prevalence of pneumonia has overall declined with childhood vaccination, the number of children with complicated pneumonia has remained stable. Current guidelines do not adequately address antibiotic management of pediatric complicated pneumonia specifically when to utilize methicillin-resistant Staphylococcus aureus (MRSA) coverage, likely contributing to …

Supraclavicular Neck Mass In A 14 Month Old Boy, Jana Ghulmiyyah

Research Days

Background: Lipoblastoma is a rare benign tumor arising from embryonic fat cells in children younger than 3 years of age. They rarely present in the neck and usually do not have spindle cell appearance. We therefore present a case of neck lipoblastoma with review of the literature.

Case Description: We present the case of a 14-month-old male who presented with 1 month history of a right supraclavicular neck mass that was enlarging gradually. On physical exam, it was non tender, mobile with no overlying skin changes. Patient did not have any respiratory distress. A fine needle aspirate (FNA) showed spindle …

Diagnostic Features And Clinical Outcomes Of Children With Tubulointerstitial Nephritis And Uveitis Syndrome (Tinu), Christian Oliveros

Research Days

Background: Tubulointerstitial nephritis and uveitis (TINU) syndrome is an inflammatory disease that affects the kidneys and eyes. TINU is rare, but likely under-recognized due to variable clinical presentation, nonspecific symptoms, and lack of universally accepted diagnostic criteria. The optimal treatment approach in children with TINU remains unknown.

Objectives/Goal: The purpose of this case series is to contribute further knowledge to this rare disease by describing disease features and treatment response of patients with TINU treated at a single center.

Methods/Design: A retrospective chart review was performed of children diagnosed with TINU at a single tertiary care children’s hospital since January …

Development Of Medical Alert Cards Using Structured Data To Assist In The Management Of Children With Anorectal Malformation, Cloaca, And Cloacal Exstrophy, Ninad Prasade

Research Days

Introduction: Anorectal malformations (ARM), including cloaca and cloacal exstrophy, are a rare collection of congenital disorders of the distal hindgut resulting in lifelong anatomic and functional impairments. Children with ARM may often have other congenital anomalies in the VACTERL association (vertebral, anorectal, cardiac, tracheoesophageal fistula, renal, limb), leading to anatomic variations and prior surgeries that require consideration in diagnosis and management. Patients with these conditions may have multiple presentations to the healthcare system. Understanding emergencies specific to these conditions can enable patients' families and providers to quickly recognize important anatomic variations and initiate care management.

Aim: Our study aimed to …

Initiating Coordination Of Care For Children In State Custody Or Shelter Care, Angela Doswell

Research Days

Problem Statement/Question: Children in the foster care system experience barriers to continuity of care, both in the primary and subspecialty outpatient settings.

Background/Project Intent (Aim Statement): To decrease average percentage of scheduled but missed specialty appointments whose initial referrals were placed in the Foundations Foster Care Clinic (FCC) from 40% to 20% over a 10- month period from March-December 2020.

Methods (include PDSA cycles): Referrals to specialty clinics were placed during an initial or follow-up visit in the Foundations Foster Care Clinic (FCC). One PDSA cycle was performed and involved notification of the patient’s case worker when a referral was …

Nasal Chondromesenchymal Hamartoma: A Case Report And Review Of The Literature, Jana Ghulmiyyah

Research Days

Background: Nasal chondromesenchymal hamartoma (NCMH) is a rare benign tumor of the sinonasal cavity. It commonly presents in infancy, however there are reported cases of adult tumors. As of August 2021, there have been 56 reported cases in the literature. This is the first description of a solely endoscopically resected NCMH in a neonate in addition to a review of the literature.

Case Presentation: A 5-day old male patient born at term presented to our institution for stridor and cyanosis since birth. The patient was reported to have desaturations while feeding at the outside hospital. On bedside examination, the patient …

Automating A Well Child Visit, Daniel Merrill

Research Days

No abstract provided.

Burnout In Pediatric Nephrology Fellows And Faculty: Lessons From The Sustainable Pediatric Nephrology Workforce Project (Superpower)., Susan M. Halbach, Kartik Pillutla, Patricia Seo-Mayer, Alan Schwartz, Darcy K. Weidemann, John D. Mahan

Manuscripts, Articles, Book Chapters and Other Papers

Physician well-being is an important contributor to both job satisfaction and patient outcomes. Rates of burnout among physicians vary by specialty, ranging from 35 to 70%. Among pediatric residents, longitudinal data demonstrates consistent rates of burnout around 50-60%, although little is known about burnout among pediatric subspecialty fellows. Specifically, the degree of burnout among pediatric nephrologists remains unknown, as does the impact faculty burnout may have on trainee burnout. We sought to evaluate prevalence and predictors of burnout among US pediatric nephrology fellows and faculty, and assess for interactions between groups. In this multi-center pilot survey of all United States …

Large Single Center Experience In Pediatric Oncology And Bone Marrow Transplant Patients On Ecmo: How Should We Decide Candidacy?, Jordan Marquess

Research Days

Watch recording of live presentation

Background: ECMO is rarely utilized in pediatric oncology and bone marrow transplant (BMT) populations due to concerns surrounding poor prognoses and high rates of complications. Patients with malignancies are often not offered ECMO as an option. There is paucity of data to determine whether a pediatric oncology or bone marrow transplant patient is an appropriate candidate for ECMO.

Methods: This is a single center retrospective cohort study on pediatric patients with primary oncologic diagnosis or history of bone marrow transplant who required VA- or VV-ECMO from 2015-2020.

Results: Twelve patients were identified with a 58% …

Safety, Timing And Outcomes Of Early Postoperative Cardiac Catheterization Following Congenital Heart Surgery, Karoline Krzywda

Research Days

Watch recording of live presentation

Background: Early postoperative ( < 6weeks) cardiac catheterization (EPOCC) has been considered high risk and often delayed. Recently, the safety of EPOCC has been demonstrated. The optimal timing of catheterization and its outcomes in struggling postoperative patients remains uncertain.

Objective: To describe EPOCC in our center and its impact on length of stay (LOS), number of mechanical ventilation days, number of ECMO days, and catheter-based interventions.

Methods: This is a retrospective cohort study of patients who underwent cardiac surgery between 01/01/2010 and 12/31/2019 and EPOCC within 30 days after surgery. Cohorts were early EPOCC (≤72 hr) vs late EPOCC ( >72 hr). Data on timing, indication, and complications of EPOCC; days of mechanical ventilation and ECMO; and CICU/total hospital LOS were collected. Data was analyzed using chi-square and Student’s t-test, …

Ekg Technology: It Is Time For A Change!, Megan Carroll

Research Days

Watch recording of live presentation

Background: Technology for obtaining pediatric EKGs has not changed in over 70 years. Current guidelines recommend a 12-lead EKG, which takes approximately 7 minutes to complete. Newer adult technology utilizes between 1-6 leads for EKG analysis. There has not been a study in pediatrics to assess the minimum number of leads required to attain diagnostic accuracy.

Objectives/Goal: To determine the appropriate number of leads needed to read pediatric EKGs safely and accurately.

Methods/Design: This is a single center systematic review that included randomly selected EKGs from our hospital database (2017-2020) read by two independent pediatric …

Increased Prevalence Of Parenteral Nutrition-Associated Liver Disease In Neonates With Congenital Heart Disease, Yasasvhinie Santharam

Research Days

Background: A life-sustaining therapy, use of total parenteral nutrition (TPN) allows for meeting nutritional needs of low birth weight, premature, or otherwise complex infants with conditions that prevent feeding through the GI tract. However, 40-60% of infants on long-term TPN have been shown to develop parenteral nutrition-associated liver disease (PNALD)1 , a serious condition characterized by cholestatic jaundice, steatosis, and hepatic fibrosis. Given these risks, providers must account for risk of hepatic injury when prescribing TPN, including attributes of gestational age, infection, surgical and diagnosis history2-6 . Yet with a multifactorial pathogenesis, significant heterogeneity in PNALD incidence still occurs. Looking …

Pharmacometabolomics Profiling Of Preterm Infants Validates Patterns Of Metabolism Associated With Response To Dexamethasone Treatment For Bronchopulmonary Dysplasia, Bradley C. Stockard

Research Days

Background: Bronchopulmonary dysplasia (BPD) is one of the most common health complications of premature birth. Corticosteroids are commonly used for treatment of BPD, but their use is challenging due to variability in treatment response.

Objectives/Goal: Previous pharmacometabolomics study has established patterns of metabolite levels with response to dexamethasone. We obtained additional patient samples for metabolomics analysis to find associations between the metabolome and dexamethasone response in a validation cohort.

Methods/Design: 14 infants provided 15 plasma and 12 urine samples. The measure of treatment response was the calculated change in respiratory severity score (deltaRSS) from pre-to-post treatment. Each metabolite was assessed …

Patient-Facing Antihemophilic Factor Clinical Decision Support Tool, Chandni Dargan

Research Days

Background: Hemophilia represents a medical condition suited to individualization. Adherence with prophylactic antihemophilic factor regimens ranges from 6%-167%. Clinical decision support tools (CDS) have been shown to improve guideline compliance and enhance patient adherence.

Objectives/Goal: The objective of this study is to evaluate the usability, usefulness, and satisfaction of a pharmacology-driven, patient-facing antihemophilic factor CDS.

Methods/Design: A patient-facing CDS was created to allow patients and families to explore factor levels at any time during their regimen and with the administration of different dosing regimens. Development followed a user-centered design process to ensure development of a product targeted to the needs …

Association Of Patient Demographics, Code Characteristics, And Survival To Discharge After In-Hospital Cardiac Arrests In The Pediatric Intensive Care Unit, Nathan Lavoy

Research Days

Background: Lower socioeconomic status and minority background have been linked to worse outcomes after out-ofhospital and in-hospital cardiac arrests (IHCA). Despite this, there has not been a focus on IHCA within a pediatric intensive care unit (PICU) evaluating patient demographics and code characteristics.

Objectives/Goal: The primary objective is to describe patient demographics, code characteristics, and survival to discharge of patients that suffer IHCA in a quaternary PICU. The goal of this descriptive, retrospective study is to identify possible differences in outcomes related to patient demographics, laying the foundation for further QI initiatives.

Methods/Design: Participants included patients between 24 hours and …

Neonatal Hypoxia Due To Pulmonary Artery Thrombus, Bianca Cherestal

Research Days

Background: Pulmonary artery thrombus is rare and should be considered in neonates with refractory hypoxia.

Case: Preterm female neonate had persistent hypoxia after birth despite intubation, high-frequency oscillatory ventilation (FiO2 100%), and inhaled nitric oxide. Delivery was via c-section at 33 weeks 4 days for new onset hydrops and poor biophysical profile. Echocardiogram revealed echo brightness in the lumen of the left pulmonary artery (LPA) with no color flow (figure 1a), concerning for occlusive thrombus. Chest CT angiogram confirmed the diagnosis (figure 1b, c). Hematology was consulted and recommended systemic thrombolysis (tissue plasminogen activator, tPA) with concomitant anticoagulation (Bivalirudin). Imaging …

The Effects Of Necrotizing Enterocolitis And Short Chain Fatty Acids On The Developing Brain In Mice, Maribel Martinez, Venkatesh Sampath, Paula Nichols, Wei Yu, Suban Burale, Tianhua Lei

Research Days

Background: Necrotizing enterocolitis (NEC) is a devastating disease in premature infants characterized by acute intestinal inflammation and necrosis with a mortality of 15%-30%. Approximately 50% of infants that survive NEC will develop neurodevelopmental defects[1]. Studies on the effects of NEC on the neonatal brain are limited, however it’s postulated that neurodevelopmental damage is induced via cytokine activation of toll-like-receptor 4 (TLR4) by high mobility group box protein 1 (HMGB1) on the microglia Accumulation of reactive oxygen and demyelination contribute to neuronal damage. Therapies that limit the development of NEC can potentially also limit the neuroinflammatory changes seen in NEC[2]. We …

Repeat Tracheal Aspirates In Pediatric Intensive Care Patients: Understanding Clinical Application, Edward Lyon

Research Days

Background: Tracheal aspirate cultures (TA) are regularly obtained in the pediatric intensive care unit (PICU) when clinical changes in intubated or tracheostomy dependent children occur. Positive TA results are often unable to distinguish infection from colonization. There is no data describing the frequency and impact of repeated TAs on patients in the PICU.

Goal: Our objectives were to describe the frequency of repeated TAs in PICU children and emergence of multidrug resistant organisms (MDRO), identify bacterial profile of TAs, and examine antibiotic prescribing patterns related to these cultures.

Methods: A retrospective chart review occurred on 15 patients in the PICU …

Rates Of Physical Abuse Screening And Detection In Infants With Brief Resolved Unexplained Events (Brues), Angela Doswell

Research Days

Watch recording of live presentation

Background: “Apparent Life-Threatening Events” (ALTEs) have been associated with child physical abuse (CPA). In 2016, “Brief Resolved Unexplained Event” (BRUE) and development of its clinical guidelines and risk-stratification replaced ALTE. It is unknown if there is a similar association between BRUEs and CPA.

Objectives: To determine the rate of CPA in infants presenting with a BRUE, examine differences between infants with/without CPA, and examine rates of diagnostic testing used to detect CPA.

Methods/Design: This study was part of the BRUE Research and Quality Improvement Network, composed of 15 academic and community hospitals. Subjects were infants …

Healthcare Utilization Of Victims Of Commercial Sexual Exploitation Compared To Non-Victims, Cree Kachelski

Research Days

Watch recording of live presentation

Background: Approximately 17,000 US children are victims of Commercial Sexual Exploitation of Children (CSEC) annually. Nearly 75% of adolescent CSEC victims received medical care within 6 months prior to identification. Screening tools have been developed based on known characteristics of CSEC victims; however, little is known about how CSEC victims compare to non-CSEC adolescents in healthcare utilization. Thus, appropriate medical CSEC screening settings are unknown.

Objectives/Goal: We aimed to identify where and how often adolescents presented to medical care in the 12 months prior to CSEC identification. We hypothesized that compared to controls, CSEC positive …

Cvst As A Rare Complication Of Acute Pediatric Covid-19, Erin Bolen

Research Days

Background: A previously healthy 13-year-old male was admitted to the hospital for a bacterial superinfection in the setting of recent COVID-19, including orbital cellulitis and pansinusitis with subgaleal, epidural, and subdural empyema. Further workup identified an occult, non-occlusive cerebral venous sinus thrombosis (CVST) along the length of the superior sagittal sinus.

Objectives/Goal: To evaluate the reported cases of CVST as a potential complication of COVID-19 in the pediatric population and identify meaningful trends in demographics, presentation, and diagnostic course.

Methods/Design: A literature search was run with various combinations of the following terms, always including “COVID”: “pediatric,” “adolescent,” “CVST,” “cerebral venous …